A 30 year old male with vomitings and pain abdomen

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 30 year old male who is a autodriver by occupation came to OPD with c/o pain abdomen and vomitings from 2days

History of presenting illness:
He was apparently asymptomatic 2days back. Then he developed pain abdomen which is sudden in onset, constant,
radiating to back and relieved on bending forward, located at epigastrium and around umbilicus.
He also has vomitings around 20episodes which is bilious, non projectile.

Past history 

He has history of similar complaints 6months ago for which he took medication and they were subsided

His daily routine: he wakes up at 6am and goes to work and eats breakfast at 9am and continues with his work and will have lunch at 1pm and comes home later in the evening and will have dinner at 9pm and goes to bed.
He takes alcohol 90ml whiskey daily since 10years
He has decreased appetite from 2days, he takes mixed diet and has regular bowel and bladder movements. He has inadequate sleep because of pain

Family history is not significant 

General examination:
Patient is conscious, coherent and cooperative
He is moderately built and nourished
He has no pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

Clinical images 






Vitals
Temperature: Afebrile
PR: 80bpm
RR: 20cpm
BP: 130/70mmHg

Systemic examination:
P/A: On inspection, no distension, umbilicus central,no scars, sinuses, fistula
Hernial orifices free
        On palpation, tender in epigastrium and periumbilical
         regions
No gaurding and rigidity 


Respiratory system 
On inspection shape of chest elliptical 
Symmetrical movements on respiration 
BAE+, Normal vesicular breath sounds heard
CVS: 
S1 S2 heart sounds heard, no murmurs
CNS: 
No focal neurological deficits 

Provisional diagnosis:
Acute pancreatitis 

Investigations:
Serum amylase: 641 IU/L
Serum lipase: 384 IU/L
Hg: 21.5gm/dl
RBC: 6.42
WBC: 11.93
Urea: 10
Creatinine: 0.6
Sodium: 137
Potassium:3.7
Chloride:86
Total bilirubin: 4.48
Direct bilirubin: 1.08
ALP: 343

USG



ECG



Treatment:

IV NS/RL @120 ML/HR
INJ ZOFER 4mg IV/TID
INJ PAN40 MG IV/OD
INJ TRAMADOL 1 AMP IN 100 MLNS/IV/SOS
ABDOMINAL GIRTH MONITORING






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